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Miscellaneous - 45 BANNAN DRIVE 4/30/2018 (2)
45 BANNAN DRIVE- 2101038.0-0115-0000.0 RIVE2101038.0-0115-0000.0 v i Lot & Street /L.+ Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: ES NO Permit# Plan Approval: Date: ��_ Approved by: Designer: L) dl Plan Date: ZS a Conditions: Water Supply: Town Well Well Permit: Driller: Well Tests: ChemiI Date Approved Bacteria I Date Approved Bacteria II Date Approved Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? ES NO 17ePf1� �� G4o g eo FINAL BOARD OF HE . LTH APPROVAL: , DATE: z2 APPROVED BY: • - b SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? YE Type of Construction: EWi REP New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: NO DWC Permit Paid? S NO DWC Permit# ® Installer: Begin Inspection: NO Excavation Inspection: / Needed: l �o A zo Passed: 9/71co By: � Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: By: Final Grading Approval: Date: By: nn Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: Town of North Andover, Massachusetts Form No.3 ! kORTM, BOARD OF HEALTH • F N s,�"•+::o�'''a°� DISPOSAL WORKS CONSTRUCTION PERMIT SSAC14u Applicant N ADDR i TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No._ AI , BOARD OF HEALTH Fee 175 D.W.C. No. //! TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION a The tjv6dersigned hereby certify that the Sewage Disposal System ( ) constructed, ( repaired: by J.6-AA�'D located at 4L 5 0APjt'1 was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # I dated , with an approved design flow ofgallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: Cl,I©—CX9 Engineer Representative Final inspection datc Engineer Representative Installer: Lie.#: Date: 16-- 17.-de's !6 Design En ' ee(r: 3 ✓( �U�_ Date: `7--Z-4z> H OFtijgS `s9 �o ay DANIEL G o KORAVOS m 0 CIVIL i No.37752 A���G�STER�� Q' S�DIVAL TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 10/19/00 This is to certify that the individual subsurface disposal system constructed () or repaired (X) by John Soucy at 45 Bannan Drive has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. vox e, Board of Health Inspector INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes NO Initials A. Bottom of Bed 1. Excavation to proper depth 2. With trenches,sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. B. Retaining Wa 1. Wall height ah width as specified 2. Waterproofed 3. Wall minimum 10'to lea ' g facility 4. Wall meets specifications of p Comments: C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8"per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90°change 10. 10'minimum offset to water line Comments: OLI D. Septic Tank 1. Level ✓ 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to grade 5. Manholes over center and each tee 6. 3-20"manholes 7. Inlet tee minimum 12"under invert 8. Outlet tee minimum 14"under invert ( U 9. Outlet line cemented 10. Air space 3"above tees l 11. 2"-3"drop from inlet to outlet 12. Pipe set 13. Compact base with 6"of 3/4"crushed stone under tank 14. Tank is watertight Comments: Yes NO E. Pump Chamber 1. If separate from tank,compact base with 6"of'/4"stone underneath 2. Minimum 2"pipe to d-box if gravity system 3. 20"access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions -� 11. Manual operating switch 12. Pump delivers liquid to d-box Comments: F. Distribution Box ✓ 1. D-box level 2. Minimum 0.IT'(2")drop from inlet to outlet _ 3. Minimum 6"sump 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box 6. Box is watertight ' 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe Comments: G. Soil Absorption system 1. All stone double-washed-'/4 1 ''/z" !/ -pea stone Bucket test done? 2, Minimum 2".of pea stone above distribution lines 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9"of fill graded over system 7. Toe of slope stops minimum 5'from edge of property; if not,then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree wi plan. (Max. length 100') 3. Width of trenches agree with p -Minimum 2';maximum-4'. 4. Vent present if<50 feet or speci d 5. Distance between trenches minim 4'and maximum of 6' 6. Minimum distance between trenches ' 7. Pipe slope minimum 0.005 or 6"per 100 8. Depth of trenches below outlet invert minim m of 6". ip Yes NO 9. Pipes set on stable base. Comments: I. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6"per 100' ' 3. Separation between pipe 6'maximum 4. Pipes connected at end _sG 5. Separation between adjacent fields 10'minimum 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi c� Comments: I Leaching Pits 1. Minimum inlet ' e 4" 2. Pits of concrete 3. Sidewall between 12" 48"wide 4. Access manholes on each pi 5. Pipes cemented with hydraulic ce t Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9"soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at /Q:� relative to the application of dated for plans by +cru��w� and dated -U<�with revisions dated '- 8--00 I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed—generally first inspection unless there is a retaining wall which should be done first Installer must request the inspection but does not have to be present b) Final Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built or verbal OK from engineer must be submitted to BOH,after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation-or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank,D-box,pipes,stone,vent,pump chamber,retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned "icensed Septic Installer � Date: a'( -ai 1)5Zk 15 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PEIRIN IT —7 DATE: -QD CL"RRENT D1STALLER'S LICENSEm LOCATION:_ vt car^ LICENSED DtSTAI R a c SIGNATURE: TEL HONET Ci 1 1 S CHECK ONE: REP. : NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BLTMT. Administrative Use Only 575.00 Fee Attached? Yes No Foundation As- uiit? Yes No Floor fans? Yes No Approval Date: . of "�pTM q Town Of North Andover , 4a "a ti 3r a oo` Community Development.& Services DWilam J.ireScott ctor 27 Charles Street (978)688-9531 North Andover, Massachusetts 01845 SSACNUS� Fax 978-688-9542 Board of August 17, 2000 Appeals (978)688-9541 Bill Dufresne Building Merrimack Engineering Department 66 Park Street (978)688-9545 Andover, MA 01810 Conservation Department Re: 45 Bannan Drive (978) 688-9530 Health .Dear Bill: Department (978)688-9540 This is to inform you that the revised septic system plans dated 08/8/00 for the site referenced above has been approved for repair. Public Health Nurse (978)688-9543 Variances given: Planning 1. Geo-membrane and interlock wall instead of concrete. Department (978)688-9535 2. Depth to ground water from 4' to 3'. Because of the second variance there can be no addition of rooms to this house unless on sewer. If you have any questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, Sandra Starr, R.S., C.H.O. Health Director SS/smc cc: Russem File : Town of North Andover, Massachusetts Form No.z of Moor►," BOARD OF HEALTH C •��o � 9 • �,b•�r�p•,.��, DESIGN APPROVAL FOR S11"C"0SE` SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • Applicant ``// Test No. Site Location 7 6441A"nA � Reference Plans and Specs. w - /7 60 • ENGINEER 0 DESIGN 6r DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. 02. 6 t s I E j i q7J _ — a p _ _ F i f i I _..�.�_. -- _�_.-�--.. i - _- � - - -- - - - __ s �- ,. _ _ �� � :;. •.., ,, ` 1 f I � � - � __ _. _.. _._..._-���:�..�.._�...�. �e e___� .� _.. � __ Jul -27-00 15:31 North Andover Com. Dev. 508 688 9542 P.01. Ju 1-L/-UU Ue:U4t' rau 1 U. luroiae. rG/r--LJ y/C5-YC7-V_%4 r.vt July 27, 2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover,MA 01845 RE: Title V review for 45 Bannan Drive I Dear Sandra, iEnclosed find the"Checklist for North Andover Septic Systemstem Plans" for the above- r mentioned site. The following is a list of all the`Problem' areas and deficiencies Port E ineering has found. I ,a istribution lines of field must be connected by solid pipe(NA 15,01) The proposed leaching bed does not have two deep observation holes located within s its boundaries. A second deep observation hole(and perc test)must be dug at the northeast end of the leaching field as shown on the design plans, or the proposed °r system must be moved to include the two previously excavated holes. ' Pump performance curves were not submitted. 310 CMR 220(4)(rj. (It appears that a '/2 horsepower pump may create excessive velocities of eMuent discharge into the U" dbox.) If you have any questions or comments please feel free to contact me. Sincerely Paul D. Turbide,PEIPLS Bannan45.doc Post4tm Fax Note 7671 Dace] , Pages► Fro PORT U/—� j 1 m :"9" S. Cu./Dept. It I Co. ENGINERING Phone# Phone# Fax# Fax# Civil Engim-ere& Land Surveyors One Ha rria S lrrr t *w6urypu►I.Ha 419so t978)4f5-A:'N i, � �''' Q • � � ' � .y y;, �� ";� •,,..��� // • f ,a z g r s` L Y + r ` A�� k•' `' - i r"a ;` '' � a r ash - sz. 7 �" s• �. � �� . y4�x.<. � - w_q .t' _....... MODELS: FEATURES: LE31 M 115% 10.5a, Manual •Vortex impeller,made of high temperature*RYTON® LE31 A 115V, 10.5a, Automatic permits passage of solids without clogging •Cast iron construction with all stainless and Automatic models feature a mercury-free wide angle brass fasteners float with series plug-allows for manual operation of pump separate from switch. •416 stainless steel rotor shaft •Oil-filled,thermally protected motor • Permanently lubricated bearings • Unitized shaft seal • 10'U.L.approved power cord with quick disconnect design allows replacement of cord in seconds without breaking seals to motor(20'optional) • 1-1/2" FNPT discharge *RYTONO is a registered trademark of the Phillips 66 Company LE30=SERIES TECHNICAL SPECIFICATIONS PUMP IMPELLER The pump(s)shall be model The pump shall have a VORTEX style impeller as manufactured by Liberty Pumps, Bergen, NY, made of high temperature*RYTON®, capable of or equal. passing a minimum 3/4" spherical solid. The pump(s)shall have a capacity of GPM at SEAL a total dynamic head of feet. Motor size shall be 1/3 horsepower, single phase, 60 hz. and 115 The shaft seal shall be of the carbon/ceramic volt operation. unitized design, with BUNA N elastomers and MOTOR stainless housings. The pump motor shall be of the submersible EXTERNAL CONSTRUCYJON type, oil filled, hermetically sealed and shall be The pump volute, legs and motor housing thermally protected.The overload element shall shall be heavy gray iron castings, class 25 or automatically reset when motor cools. Motor better. All castings shall be enamel coated before windings shall be of the class A insulation rating. assembly.All fasteners shall be of 300-series The rotor shaft shall be made of 416 stainless stainless steel or brass. steel and shall be supported by lower bronze LEVEL CONTROL and upper sleeve bearings. The pump shall be controlled by an adjustable mercury-free switch sealed in PVC float, and shall have a series plug for manual by-pass operation. MODELS HP VOLTS PHASE AMPS DISCHARGE AUTOMATIC IMPELLER LE31 M 1/3 115 1 10.5 1-1/2" FN PT NO VORTEX LE31 A 1/3 115 1 10.5 1-1/2" FN PT YES VORTEX 10'cord standard on above models. For 20'option,add a"-2"suffix to model number.Example:LE31 A-2 DIMENSIONAL DATA: PERFORMANCE CURVE Weight: LE31 M:31 LBS. 20 1550 RPM 6-- Height:9.6"Height:9.6" s Major Width:9.8" (manual models) d 4 12 Maximum fluid temperature 145 degrees F. 'RYTONO is a registered trademark of the Phillips 86 Company 2-- 4;d h "Fq.r f UM 0 0 - 10 20 30 40 50 60 pl� U.S.Gallons Per Minute co-Certified ii ii 0 1.4 2.8 4.2 City of LA certification available MEMBER Liters Per Second Liberty Pumps• 7307 Lake Rd 9 Bergen,New York 14416•Phone(716)494-1817 Fax(716)494-1839 7240-111/94 '� a �, i :��---- .,- -- _ __ __ � _, — — — � } — — — — � d c-- `` III �� � — i a ., 1 i � I PAGE 1 OF 5 Commonwealth of Massachusetts Application for Local Wgra, de Approval Tale 5, 310 CMR 15.000 DEP Approved form required by 310 CMR 15.403(1) To be s bmitted to Local Amroving Aur by/Board of Health: For the upgrade of a failed or nonconforming system with a design flow of <10,000 gpd, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or nonconforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full compliance, as defined in 310 CMR 15.404(1), is'not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or'the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15.000. 1) Facility/system owner Name Imo . : s5�►�► - Address 92^62 S4i,�►�1r� �!E Phone Address of facilitye-�x4tAe7 -- 2) Applicant'(if different from above) Name emr —i 0-- Address rAddress Phone 3) Type offac at(residential _commercial _school _ institutional (Specify) DQ APMOM FORM-UMMf 4 PAGE 2 OF 5 4) Type of existing system privy cesspool(s) ✓ conventional system Other (describe) Type of soil absorption system (trenches, chambers, pits,etc.) 5) Design flow based on 310 CMR 15.203 a) Design flow of eisting system q4O gpd Approved? yes approval date no why? b) Design flow of proposed upgraded system gpd c) Design flow of facility gpd 6) Proposed upg}pde of existing system is a) ✓ Voluntary Required by order, letter, etc. (attach copy) Required following inspection required by 310 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) F ' b) .Describe the proposed upgrade to the system i5,�P1TI N6 I©e%, 6AL, —rAgs o M inJ C) Which of the following are applicable to the proposed upgrade? .AjA, Reduction of setback(s) (list setbacks to be reduced with► Proposed setback distances) Qom. Petocolation rate of 30-60 minutes per.inch (state actual Perc rate) 00 AMOVW!OW-1!10 M N PAGE 3 OF 5 AWA Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) Relocation of water supply well (identify well, describe relocation) Reduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) C4 1-k A. Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the Code) System upgrades that cannot be performed in accordance with 310 CMR 15.404 & 15.405, or in full compliance with the requirements of 310-CMR 15.000, require a t variance pursuant to 310 CMR 15.410-15.417. 7) If the proposed upgrade involves.& reduction in the required separation between the bottom of the soil absorption system-and the.high groundwater elevation, an Approved Soil Evaluator must determine the.high ground water elevation pursuant to 310 CMR 15.405(1)(i)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater rP _ feet As determined by: Y Evaluator's namera � ►gyp - Evaluator's signature Date of evaluation G-J DO AMovm FORM.1=195 PAGE 4 OF 5 8) Notice to Abutters No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property or well is affected by certified mail at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. If the Department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the Department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. List of affected Abutters: Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 1 9) Explain why full compliance, as defined in 310 CMR 15.404(l), is not feasible (each section must be completed): a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible: b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible: i DQ AMOVFD FORM-UM196 PAGE 5 OF 5 c) a shared system is not feasible: AjA d) connection to a sewer is not feasible: 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? fires z,/no 11) Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowi lations." 711f/,z 1, 0.3 4a2ctili�tyy owner' f signature at e75 Print Name t . 0-446-r, Cr46 l rJOMA�� Name of.preparer Date Telephone # & address of preparer NOTE: Title 5, 310 CMR 15.403(4), requires.the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. M A"WV n VowN-wrrns •- FORM 11 - SOIL EVALUATOR FOIMI Page 1 Date... r.......... No................................ ........... Commonwealth of Massachusetts Massachusetts Foil SWMI& Assessment for 4n-side SeWM, Disposal Performed By: ..._.. .� _..._� �� --..�_ �.._ ..._......._._. ........ Witnessed By: .........................................................___...�...............................................:..............__..�.......... . ............... LA 0 New Construction ❑ Repair 0" Office Review Soil Survey lam" Published y Available: No 0 Yes i� � 5 .Year Published J,��t..`... Publication Scale _.........--...•• Soil Map Unit.... .... Drainage Class /�J..... Soil Umitations .......... ...... .. . ................ ... .._... ........:..�:.:..._..................... Surficial Geologic Report Available: No Yes ❑ Year Published .__._......-... Publication Scale ....•.•.•.•.•••••• GeologicMaterial (Map Unit)...._...................._........................................................_..._. ............................................... Landform ....................................................._..................................................,........_...................................._............................ Flood Insurance Rate Map: l Above 600 year flood boundary No ❑ Yes ❑/ Te Within 500 year flood boundary No Yes ❑ 1 . 4. ❑ Within 100 year flood boundary No EY/ Yes •� ; 7 Wetland Area: National Wetland Inventory Map (map unit)...................................-—� - ---- w-- -�--- --- maunit) Wetlands Conservancy Program Map (map Current Water Resource Conditions (USGS): Month • ••• Range : Above Normal Normal ❑ Below Normal ❑ Other References Reviewed: VORhi It - SOIL RVAWA'DOR VORM .. y Pago2 OR-site view Deep Hole NumberWeather Location lldandfy on site plan) ._.._______ Land Use ' ' Sloe 1461 ? 1" Surface Stones n" .�_.- Vepetatlon _ ..__ _.._ _____ _ ... . _ ._w ._....._.....-.._-....._.........._._ - lartdform posldon on landscape(sketch on the back( Distanced from: Open Water Body ?iceWAV-411F feet Drainage feet, Possible Wet Area ZY?R feet Property line.� �+ feet Drinking Water feet Other - ---�.-- .---.- - DEEP OBSERVXTION HOLE IM' G DE Myth from 6utf�a 6oN halwM Sd T�tdura SOM Gctar SON IAptlun0 tlnafwsl W8DJ1! llAunadM f8trtiottr�, two n� Area l A Ap. <.. . ' h`s 0, . 3 /v 5Y �3 Parent Material lgeologlcl � Depth h to Bedrock. 1388th - to Oroundwgil Standing Water In the Hole: E� Wsaping from Pit Face: _7 Z i Estimated Seasonal High Ground Water: .../•• . DORM It - SOII. EVALUATOR I10g Pelle 3 Dat y mina . nn foWater Table ❑ Depth observed standing In observation hole inches ❑ Depth weeping from side of-observation hole inches [] Depth to soil mottles. lnohes Ste- f.41 -z- 0 ❑ Ground water adjustment feet Index Well Number Reeding.Data Index well level Adjustment factor Adjusted ground water level . .. Dnth of Naturally Oeourrina P-8rAdQUA Material Does at least four feet of naturally occurring pervious material exist in.eil areas + observed throughout the arse proposed for the soil absorption system? If not, what is the'deptli of naturally, occurring pervious material? I certify that on (date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 16.017. Signature _W_AAI� 4PW 4- _Zq FORM 12 - PERCOLATION TI+ST COMMONWEALTH 'OF MASSACHUSETTS �•l,�x° 0 � , Massachusetts Pemolatfon Test Date: Observation Hole # Depth of Parc Start Pre-soak Ip qk end Pre-soak ' y Time at 12" 0.3. Time at 8" Time at 6" Time W-6`I ..i Rate Min./Inch Site Passed .19/Site Failed ❑ ..._... _ _._....._. ..._... .._.._..._ ._. . Performed By: / , Witnessed By: Comments: ................................. __..._..._.................................................................................. _.............................................. ............................ T(7. C i 6 MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNER-- _ 66 PARK STREET•ANDOVER,MASSACHUSETTS 01810•TEL(978)475-3555,373-5721 •FAX(978)475-1448•E-MAIL:merreng@aol.com TO: North Andover Board of Health FROM: Bill Dufresne/Merrimack Engineering DATE: 7 RE: gs TM: *Z2 t2,2 TL: 1 1 OWNER(NAME & ADDRESS) rZa 57e7 c►- I 6?46&JN �i Ifo Afs V X12,, h4051 Members of the Board: An upgrade sewage disposal system plan dated: has been submitted for the above referenced site. Pursuant to Title 5, and the North Andover Board of Health Regulations, Local upgrade approval and/or variances are being sought from the following sections. 2) .v-Z, i2ETk 10 l A'u—s 3) Please consider these requests for approval on your earliest available meeting agenda. We respectfully request your consideration of these matters. Very truly yours, MERRIMACK ENGINEERING SERVICES William Dufresne k JUL 7 I cd 1 ����� �: _ ,: '��,�� e , r �� �� �°" fr,; �'� " °' �' � Ii r .� J T��f6",� ' • � L � � s ='' � E �� i� .t s�e r�-,'.t , �'4 � � � i" I ��,z '� � t '7 C � ill!. �'. � ��i yt � � � / � ! ':e / 0 / ... ��=-', � - .- ,I► � �, r: '`' � � �� v�, T4i1. ��� � h':, s � '- �. � :i •� ��. F �'�� y � ' � y: �� {Ii �` 1 { y. �, s f� {,:' ny�Y a� ., *��. a� s�z:'�:- � _ t+�Ax M �k` pk�., - "':'SZ*• ...T 'WL+'-"RYFYP rCv. d f V`b. J r, 4 S A p r� ya s "Ja �,� In hR q r Fes t '6'6$x'4.• A ^ � ra z 4,ysA # - �i„$ffihY.:r�• a+:rpc- + _ +-"'�t�Y..."-�5' k+�,,� �'su?� kyai b 4 id u, s s y �ffir ' �n t s} Y us •�csd. t .�f�x�`a bry+�+� }r il°� �&�r�fy,�'t, �� to rs v yx f fi e•� yF'Y rY F�T `�c .•,� r��''�r�'d�,rtbah �C(r,,t��t�W$��°��i w rt .°rid a y rS € }�y>w II Fzbs Cc fl"S.rii '�.:�Fr.�i^,wwt.� . .,.� Y...r :k `t e R M - S t 1�AS.y�x3 kke�� �eIEl9 � FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 0 rl�0 Date: w No. Comm nwealth of Massachusetts Massachusetts Soil Suitabili Assessment or On-site Sewa a Dis osal N! �........... (,........ - NNI .......................... Date: Performed By: ............IW.........r�i.. C�. lWitnessed By: ......... IJ.`.....Sf2t2E...19.YU ...f4!vbG�. C....�30W.RlJ... ....N� . -/�f......... .......................... N ,�n.lyr � rName. ,CC �uSS� Lomion Address a /(7C— (3(F�v'" Address.and Los N �u)2 Telephone/ 4� Y7 iYU�vl A , ew Construction ❑ Repair 5v�) `731 — ywv Office Review I Published Soil Survey Available: No ❑ Yes ! ` /S. Soil Map Unit �� .............. Year Published �.�. ..�....• Publication Scale �• (... ................................................. Drainage Class n�ao�irg M�.Y..W . Soil Limitations ................................................... Surficial Geologic Report Available: No Q Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit) .......................................................................................................................................................... Landform ...................................................................................................................... .......................... Flood Insurance Rate Map: I Above 500 year flood boundary No ❑Yes Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No []Yes ❑ ' Wetland Area: National Wetland Inventory Map (map unit) .......................................................................... .. .................................................................................. ............... Wetlands Conservancy Program Map (ma p unit) Current Water Resource Conditions (USGS): Month -- Range :Above Normal ❑Normal ❑Belc,.v Normal ❑ Other References Reviewed: I ' DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. 4 22 MVK'V DI21 Vt� On-site Review Deep Hole Number . /%3 v Weather 70"' C—�uv.y Date.,.:.::::...:..... Time: Location (identify on site plan) ...:::::::::::.::.:... ... . Land Use LMW^/ Slope (%) &-/S Surface Stones n/Q.: Vegetation Landform Position on-landscape (sketch on the back) . Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Well feet Other DEEP OBSERVATION HOLE _OG' Depth from Soil Horizon Soil Texture Soil Color Soil Other (USDAI (Munsell) Mottling (Structure,Stones, Boulders, Consistency, Surface(Inches) 4 - 10 3 (FILL) 5H'7I3 Frz14131AE 10- C I LS Z'SYSJ�° MZ! /nye &,ZigvaL � 5Y 6/3 Gr�L Z+S K/& M�4JS1v�iFpLi[9�3L� --7g Z 7,SN�24/!0 3P E5 K 1C LDepthto8edrock: f3 /eucK Krr=uJafC.- Parent Material (geologic) i i Face: � _ Weeping from Pit Doth to Groundwater: Standing Water in the Hole: V Weep 9 N Estimated Seasonal High Ground Water: i pEp APPROVED FORM-12/07/95 FORM. 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. 45- 13MAWOAI 6P-f v9 On-site Review ' Z O/L,1QG Time:.. ..�� � Weather 7p� Deep Hole Number Date:..:.:::. .:...::... Location (identify on site plan) .....:,: e Land Us LdtWn//L.j.o U oS Slope(%) .3— ib Surface Stones Vegetation vRS:,..13rLu.Svl ., �o�Sw. .1u Landform .. . . Position on-landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Well feet Other DEEP OBSERVATION HOLE '-OG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravep_ Af� f SCr �. Z(, 8w FSC 10lia5/8 Mlf�51uy, r-f14r3t,C 5y.7/3 - ZC- tiv C, LS Z,S'15�(0 7,S`fS�G M�ssr vt, Fri� 3 Parent Material (geologic) Tj(- . Depthto8edrock: yo / g r-vj,4c 1✓ _ Depth to Groundwater: Standing Water in the Hole: ¢ Weeping from Pit Face: U,r -- Estimated Seasonal High Ground Water: DEP APPROVED FORM 12/07/95 I FORM 11 - SOIL LVALUATOR FORM Page 3 of 3 Location Address or Lot No. 4S 364N�✓�1N 0�«� Determination ,dor Seasonal High Water Table Method Used: I I ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole ................. inches a Depth to soil mottles 14-t.2 4.... inches ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date ................... Index well level ................... Adjustment factor ................... Adjusted ground water level ........................................................ CDepth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material. exist in all areas observed throughout the area proposed for the soil absorption system? yeS If not, what is the depth of naturally occurring pervious material? Certification I certify that on 101q4- (date) I have passed the soil evaluator examination R Environmental Protection and that the above analysis approved by the Depa tment Y C was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Date 9 DEP APPROVED FORM-12/07195 FORM 12 - PERCOLATION TEST Location Address or Lot No. 45 9K1VN;4/V -DSIy COMMONWEALTH OF MASSACHUSETTS NO2I**V1 AwDuv.i✓l_ , Massachusetts Percolation Test Date: Ly �� �Q� Time:.....:....../ GO.::. :: ... ........ Observation Hole #. j Depth of Perc O /� Start Pre-soak / r( End Pre-soak Time at 12" Time at 9" 3 Time at 6" 4 Time (9"-6") l'U ,vlc�✓t Rate Min./Inch 3 Nl v-V/i/ * Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed Site Failed ❑ ..............................................................................................:.......................................____......_......_ Performed By: bijAn l G L 6'c,0.vniC cam. - Witnessed By: ST>+UL Comments: :.._.... ..............,................. .. ............................................................. ...................,....................................... DEP APPROVED FORM-12/07/95 3 RAJNAW ul 4S TPA p-l n� MUJ i rS� {?h�'►uv�� iII I ' ( tom r7 - _ I i I - �r i � •" i i i I it I _Z P/=Ccs I � i ��✓a`A•'_-� 1O cis c � •��-r-i I ,�S�_ II �s �� X531 7 + old .531 0 . S8 :BAI O I ndn rlb . G»OJ/� .t I � y 5 st: " 7 - 1 � ��-�� _ �''_ _ roe .I //Y3LY��•� 0� .Ss •is,Q � \ 00052 X2,92 \ • 06 7?v Q-Fs14-:ia sa' '077,ll'Pb'Pa'd8' ' Hoo'--75V-0 �1 on/YV 'oYy �'� .; sn��Q rvdrvrvy8 ? -xt 107 C ` I i LCCA,TION IN, � EOIL--'IVVI � pct 0i ^, 1-10 N I =.S T I TIME 1NiC A i ` IILi` I E f; I 1 I I j ilei= E 17 TNIE— I r f 1 IrV lid i^. HOI�Try ��O•` ,.ao •,SOL n BOARD OF HEALTH 30 SCHOOL STREET NORTH ANDOVER, MASS. 01845 TEL. 978 688-9540 May 21, 1998 45 Barman Drive North Andover,MA 01845 RE: Non-compliance with 310 CMR 15.000 Dear Mr. Russem: It has comes to the attention of the North Andover Board of Health that you had an inspection of your septic system in December of 1995 which determined that the system was failing to protect public health and safety and the environment. Soil testing was performed in August of 1996 but to date there has been no further action to repair the system. The soil tests performed will expire in August of this year. The time allotted by.Title 5 to repair the septic system has already expired. You are hereby notified that you are in non-compliance with 310 CMR 15.305 and must immediately take the following action: 1. Hire an engineer or Massachusetts Registered Sanitarian to design plans for the repair of the septic system at 45 Bannan Drive. 2. Submit these plans to the Board of Health for review accompanied by a check for$60.00 made out to the Town of North Andover by June 11, 1998. Please do not hesitate to call the Health Department at the number above if you have any questions. Sincerely, Sandra Starr,R.S. Health Administrator. Town of North Andover, Massachusetts Form No. 1 NORTH " • BOARD OF HEALTH 0 19 APPLICATION FOR SITE TESTING/INSPECTION �,9 A�R4TEo PPP�.(y SSACHUS� Applicant NAME ADDRESS / TELEPHONE r Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee r 7 Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. s COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL A.>FFAIRS n� d DEPARTMENT OF ENVIRONMENTAL PROT'ECTI� 2C' y, >:_•.�..-may , TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Viiay Kathuria Owner's Address: Same Date of Inspection: 04-12-2004 Name of Inspector: (please print)John Soucy_ Company Name: Soucy Sewer Service,Inc. Mailing Address: 830 Livingston Street Tewksbury,MA 01876 Telephone Number: 978-851-8839 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that t1he information reported below is true,accurate and complete as of the time of the inspection.The inspection was perf6rmed based on my training and experience in the proper function and maintenance of on site sewage disposal systtems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs F.Arther Evaluation by the Local Approvimg Authority Fail 4 * Inspector's Signature: Date: q`ZR'a 2.0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a dlesign flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicabile,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the condifiions of use at that time.This inspection does not address how the system will perform in the future under tthe same or different conditions of use. e i 1 - _. ... a Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI0111'1 FORM PART A CERTIFICATION(continued) Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Viiav Kathuria Date of Inspection: 04-12-2004 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need t®be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined()(,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or nod)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System widll pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distributiom box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inslpection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: i The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI0110'1 FORM PART A CERTIFICATION(continued) Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Viiay Kathuria Date of Inspection: 04-12-2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to dettermine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMB 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt mares 2. System will fail unless the Board of Health(and Public Water Supplier,if any)dietermines that the system is functioning in a manner that protects the public health,safety and environnnent: _The system has a septic tank and soil absorption system(SAS)and the SAS is witlhin 100 feet of a surface water supply or tributary to a surface water supply. —The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _The system has a septic tank and SAS and the SAS is within 50 feet of a private wkater supply well. _The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feett or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution$rom that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,1provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Viiav Kathuria Date of Inspection: 04-12-2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"n6"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged[SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool T X Static liquid level in the distribution box above outlet invert due to an overloaded®r clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less thin'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstmucted pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or trilbutary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet fronn a private water supply well with no acceptable water quality analysis. [This system passes if the;well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile oaganic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner shouad contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10;1(100 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply T _the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area.—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Viiav Kathuria Date of Inspection: 04-12-2004 Check if the following have been done.You must indicate"yes"or"no"as to each of the folhowing. Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x _ Has the system received normal flows in the previous two week period? x Have large volumes of water been introduced to the system recently or as part of'dhiB ii pec ion? x _ Were as built plans of the system obtained and examined?(If they were not avaibble note as N/A) x _ Was the facility or dwelling inspected for signs of sewage back up? x Was the site inspected for signs of break out? x _ Were all system components,excluding the SAS,located on site? x _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth off:sludge and depth of scum? x _ Was the facility owner(and occupants if different from owner)provided with inf®nmation an am pl par maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No x _ Existing information.For example,a plan at the Board of Health. x Determined in the field(if any of the failure criteria related to Part C is at issue a1pproximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] II Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Viiay Kathuria Date of Inspection: 04-12-2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_330 Number of current residents: 4 Does residence have a garbage grinder(yes or no):no Is laundry on a separate sewage system(yes or no): no [if yes separate inspection requiredM Laundry system inspected(yes or no): no Seasonal use:(yes or no): no Water meter readings,if available(last 2 years usage(gpd)): See Attachment Sump pump(yes or no): no Last date of occupancy: recent COMMERCIAL/INDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Home Owner Was system pumped as part of the inspection(yes or no):yes If yes,volume pumped:_1000_gallons--How was quantity pumped determined?Gage on tmuck Reason for pumping:Maintenance and inspection of tank interior. TYPE OF SYSTEM —X Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 10/19/2000 Were sewage odors detected when arriving at the site(Yes or no):No �. . _. e Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Viiay Kathuria Date of Inspection: 04-12-2004 BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction: X cast iron _40 PVC other(explain): Distance from private water supply well or suction line; N/A Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: x (locate on site plan) Depth below grade: 14" Material of construction: X concrete_metal_fiberglass_polyethylene_other (explain) If tank is metal list age:_Is age confirmed by a Certificate of Compliance(yes or no):ii(attach a copy of certificate) Dimensions: Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 38" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined:_Tape&Sludge Tool Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) N/A Depth below grade:_ t Material of construction: concrete metal fiberglass_polyethylene,other(expllain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Viiay Kathuria Date of Inspection: 04-12-2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)N/A Depth below grade: Material of construction: concrete metal fiberglass_polyethylene othew(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: equal_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryower,any evidence of leakage into or out of box,etc.): Flow Checked Okay PUMP CHAMBER: X (locate on site plan)N/A Pumps in working order(yes or no): Yes Alarms in working order(yes or no): Yes Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Way Kathuria Date of Inspection: 04-12-2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: X leaching fields,number,dimensions:Leaching Field 15'x 60' overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): No Sign of Hydraulic Failure. 1 on site plan)N/A CESSPOOLS: (cesspool must be pumped as part of inspection)(locate p ) ( P Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vggetation,etc.): PRIVY: (locate on site plan)N/A Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vggetation,etc.): Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Viiav Kathuria Date of Inspection: 04-12-2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent referemce landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. ZI I N � - R � >CA�� y_- --- - - _ ..g V CL Is II 6 c J • i � Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 45 Bannan Drive North Andover,MA 01845 Owner's Name: Way Kathuria Date of Inspection: 04-12-2004 SITE EXAM Slope Surface water Check cellar x Shallow wells Estimated depth to ground water 3 feet plus. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewedt: X Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: High ground water elevation determined from test pit plans dated 8-8-2000. 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